refinements are viewed as part of a natural evolution and improvement process and, therefore, need not be applied retrospectively. The committee does encourage rapid implementation in order to provide the benefits of an improved system to new enrollees.

The committee recommends improved documentation of the screening used during Phase I for patients with psychological conditions such as depression and posttraumatic stress disorder (PTSD). The DoD (DoD, 1996) reported that depression and PTSD account for a substantial percentage of those receiving a diagnosis of a psychological condition. In addition, if there are long-term health effects of nerve agent exposure, it is possible that these effects could be manifested as changes in mood or behavior. The committee will be conducting an in-depth examination of the adequacy of the CCEP as it relates to stress and psychiatric disorders at a later time; however, because of the increased importance of ensuring that all possibilities are thoroughly checked, better documentation in this area is encouraged. Primary physicians could use any of a number of self-report screening scales, but consistent use of the same scale across facilities would ensure consistent results.

The committee recommends improved documentation of neurological screening done during both Phase I and Phase II of the CCEP. Concern about nerve agent exposure as well as the number of nonspecific, undiagnosed illnesses among CCEP patients makes documentation of neurological screening extremely important. CCEP patients are referred to neuromuscular specialists if they have complaints of severe muscle weakness, fatigue, or myalgias lasting for at least 6 months that significantly interfere with activities of daily living. These patients are evaluated by board-certified neurologists who have subspecialty training in neuromuscular disease. Based on the description of the tests administered and examinations conducted, the committee finds that the CCEP is sufficient to ensure that no chronic, well-established neurological problem is being overlooked. The documentation of the use of these tests and procedures, however, could and should be improved. Such improvements would engender confidence that neurological examinations and treatments across facilities are comparable.

Given the importance of thorough neurological and psychiatric screening, the committee recommends that Phase I primary physicians have ready access to a referral neurologist and a referral psychiatrist. As mentioned earlier, patients are referred to neuromuscular specialists if they have complaints of severe muscle weakness, fatigue, or myalgias lasting for at least 6 months that significantly interfere with activities of daily living. Appropriate psychiatric referrals could include those with chronic depression that is treatment resistant, an unexplained, persistent complaint of memory problems, or significant impairment secondary to behavioral difficulties, such as not being able to maintain productive work due to behavioral abnormalities. While patients referred for Phase II consultations with a neurologist or psychiatrist are cared for adequately, it is sometimes difficult for the primary physician to determine



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